The National Athletic Trainers' Association has released a new position statement on the management of sport concussion. The release came during the NATA's 5th annual Youth Sports Safety Summit in Washington, DC. in March 2014.

The statement is an update to the NATA's original 2004 concussion guidelines (Guskiewicz KM, et al. 2004) and addresses education, prevention, documentation and legal aspects, evaluation and return-to-play considerations. In particular, the authors amended the return-to-play guidelines and now recommend no return on the day the athlete is concussed. (Note, this brings the NATA in line with the consensus of experts, which has recommended no same-day return-to-play for a number of years).

The statement, created by the NATA Research & Education Foundation, appeared in the March 2014 issue of the Journal of Athletic Training,

"With the continued national spotlight on concussions from professional to youth sports, these recommendations provide a practical roadmap for athletic trainers, physicians and other medical professionals on injury identification and management. We also hope this document will serve as an educational tool for parents and school administrators," said Steven P. Broglio, PhD, ATC, lead author of the position statement and director of the Neurosport Research Lab in the School of Kinesiology at the University of Michigan.

"Athletic trainers (ATs) are commonly the first medical experts available on site to identify and evaluate injuries," added Broglio. "Without exception, ATs should be present at all organized sporting events - from practices to games - and at all levels of play and work closely with their physician or other designated medical expert to implement these guidelines. In light of these general protocols, each athlete should be treated on an individual basis."

Highlights

Education and Prevention

The statement recommends:

Using proper terminology such as concussion or mild traumatic brain injury (mTBI) as opposed to colloquial terms as "ding" or "bell ringer," which minimize the injury severity. The recommendation that concussion and mTBI can be used interchangeably is a departure of some of the other concussion position statements and guidelines in recent years, and there has been an ongoing debate[1] in the medical community about using concussion and mTBI interchangeably. "Our thought was to try to highlight that a concussion is a serious injury, rather than the thought that it is just a ding or bell-ringer," said Tamara Valovich McLeod, PhD, ATC, Professor and Director of the athletic training program at A.T. Still University in Mesa, Arizona and one of the position statement's co-authors. "I understand the point [that those who argue against using the terms interchangeably make]," McLeod says, "that all concussions are mTBIs but not all mTBIs are concussions, but ATs are most often discussing the injury with parents, adolescents, and coaches, so we thought to simplify the message and denote the seriousness regardless of whether the term concussion or mTBI is used";

Communicate the status of concussed athletes to the managing physician, document all evaluations, management, treatment, return to participation and physician communications.

"The legislation and policy area is one that is important for ATs, because they need to not only be aware of any state laws, but also their state interscholastic association policy, school district and/or school policy, and their standing orders with their directing physician," says McLeod. "It's a multi-layered system of policies in which one could be more conservative than another. Furthermore, it is important that concussions are documented well as this injury holds a high degree of [potential] liability."

The statement's discussion of the legal liability aspects of concussion management as they relate to athletic trainers, it is worth noting, is believed to be the first such discussion in a position statement regarding concussion management.

Evaluation and return-to-play

The position statement recommends that:

Athletes at high risk of concussions (those in collision or contact sports) should undergo baseline examinations[8] before the competitive season.

Baseline examinations be completed annually for adolescent athletes, those with recent concussions and, when feasible, all athletes. (Note: this is a departure from other consensus statements, which do not call for annual baseline exams);

Baseline exams should consist of clinical history[9], physical and neurologic evaluations, measure of motor control (balance[10]) and neurocognitive functions[11]. (noticeable by its absence is a recommendation for a baseline King-Devick test, a simple vision test that a growing number of experts believe, and studies[12] show, can help identify athletes with possible concussion on the sports sideline in making the all-important "return/no return decision");

Any athlete suspected of a concussion should be removed from play; not allowed to return to activity on the day of injury; and received a full follow-up evaluation from a physician or AT;

Once the concussion diagnosis is made, the patient should undergo daily focused examinations to monitor the course of recovery and be cleared by a physician before returning to play. (Note: written RTP clearance is required under the law of 48 states and the District of Columbia[5], although some state laws allow the written authorization for return to sports to be made by health care professionals other than a physician);

Those athletes with a history of concussions or who do not show a typical return to normal functioning after injury (usually in about a week to 10 days, according to most studies) may benefit from a referral to a neuropsychologist (as a brand new study [13]in Pediatrics (Kirkwood MW, et al. 2014) recommends) or additional treatments or therapies[14]. McLeod says one of the "key aspects" of the statement lies in the fact that it "reiterat[es] the importance of the multifactorial assessment and using an interdisciplinary concussion team."

Other considerations

Equipment:

The position statement recommends:

that ATs enforce the standard use of certified (e.g. NOCSAE) helmets and educate athletes, coaches and parents that, although helmets can help prevent catastrophic injuries, they do not significantly reduce the risk of concussions;

helmet use in high-velocity sports (e.g. skiing, cycling), which has been shown to protect against traumatic head and facial injury;

the wearing of mouth guards because, although consistent evidence demonstrating a reduced concussion risk by wearing a mouthguard[15] is not available, the evidence demonstrates that fitted mouthguards do reduce dental injuries;

young athletes undergo continual brain and cognitive development and may require more frequent updates to their baseline assessments; and

ATs, school administrators and teachers work together to include appropriate academic accommodations[20] in the concussion management plan.

Home care:

The position statement calls for:

implementation of a standard concussion home instruction form for all patients;

instructing a concussed patient to avoid medications other than acetaminophen, and to avoid alcohol, drugs or other substances during their concussion recovery;

recommending rest as the best practice for concussion recovery; during the acute stage of injury (the first several days after injury) patients should avoid any physical or mental exertion that exacerbates symptoms, should maintain a healthy diet and stay well hydrated; and

ensuring that school administrators, counselors and instructors are aware of the patient's injury.

For a comprehensive article about the parents' role in concussion treatment and recovery, click here[19].

Multiple Concussions:

With respect to the management of patients with a concussion history[21], the statement recommends that:

the potential for second-impact syndrome[22] be recognized, and an awareness of the potential long-term consequences of multiple injuries; and

referral to a physician with specific concussion training and experience be considered for athletes with a history of concussions.

Concussions: key statistics

An estimated 3.8 million concussions occur each year as a result of sport and physical activity.

Sport-related concussions account for 58 percent of all emergency department visits in children (8-13 years old) and 46 percent of all concussions in adolescents (14-19 years old).

Athletes who have had one concussion are 1.5 times more likely to have a second; those who have sustained two concussions have a nearly three times greater risk and those with three or more have a 3.5 times higher risk.

The most recent data from the High School Reporting Information Online (RIO) indicated that concussions in interscholastic athletes are responsible for 8.9 percent of all athletic injuries.

For a comprehensive article on statistics on concussions in high school sports, click here[23].

More research needed

The clinical practice recommendations set forth in the NATA's statement are "graded" based on the Strength of Recommendation Taxonomy (SOR)(e.g. "A" is based on "consistent and good quality experimental evidence; "B" on inconsistent or limited quality experimental evidcence, and "C" on consensus, usual practice, opinion, or case series or studies of diagnosis, treatment, prevention, or screening, or extraopolations from quasi-experimental research.

As McLeod notes, "the grading of the SOR still finds a lot of recommendations graded with a "C", meaning there is limited evidence and it is based primarily off expert opinion. (In fact, 30 of the 46 recommendations are graded C) I think the number of C recommendations shows there is still a lot of research that needs to be done in many areas."

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To review the NATA's statement in full, please visit: http://dx.doi.org/10.4085/1062-6050-49.1.07.

The National Athletic Trainers' Association has released a new position statement on the management of sport concussion. The statement is an update to the NATA's original 2004 concussion guidelines and addresses education, prevention, documentation and legal aspects, evaluation and return-to-play considerations. In particular, the authors amended the return-to-play guidelines and now recommend no return on the day the athlete is concussed.